How the Rise of Problematic Pornography Consumption and the COVID-19 Pandemic Has Led to a Decrease in Physical Sexual Interactions and Relationships and an Increase in Addictive Behaviors and Cluster B Personality Traits: A Meta-Analysis

On January 13, 2018, an alert was sent to Hawaii's people that a missile was heading toward them. People were in a state of alarm for 30 minutes before the government sent out a false alarm statement. Fifteen minutes after the message that told the people of Hawaii that they were not in danger went out, Pornhub's views spiked by 48%. On March 11, 2020, coronavirus disease 2019 (COVID-19) was designated a pandemic. By March 25, 2020, Pornhub's views had spiked to over 24%. We took the research available on problematic pornography consumption, also referred to as internet sex addiction, pornography addiction, and cybersex addiction, and compared that to the rise of pornography use since the year 2000 and how the COVID-19 pandemic impacted pornography use and the effects it had on sexual and social relations. We also wanted to see if there is any association between pornography consumption and other addictive disorders and cluster B personality traits. There is currently no Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis for pornography addiction. We want to see if the data we gather can aid in identifying whether problematic pornography use has a place alongside other addictive disorders in the DSM-5. We hypothesize that inappropriate pornography consumption has increased since 2000, only to increase further during the pandemic. The null hypothesis, Ho, states there has been no change in the consumption of pornography since the 2000s. The alternative theory, Ha, says that the proportion of people who use pornography has increased over the past 23 years. As for other addictive disorders and cluster B personality traits, we hypothesize the research will show that greater than 50% of people exhibiting problematic pornography consumption will also have an additional addictive disorder and a cluster B personality trait. Our results support our hypothesis that during the COVID-19 pandemic, pornography consumption increased beyond the baseline. The results did not support our prediction of a significant association between other addictive disorders and cluster B personality traits with pornography consumption.


Introduction And Background
The objective of this meta-analysis is to compare how the rise of pornography use and the coronavirus disease 2019 (COVID- 19) pandemic has led to a decrease in sexual and personal connections and relationships while also correlating pornography use with other addictive behaviors, including cluster B personality traits. PubMed, Google Scholar, EBSCO Medline, JAMA, and ScienceDirect were used to establish and review existing literature on these topics.
The increase in pornography consumption has been a widely discussed topic in recent years regarding concerns about its potential effects on relationships and society [1]. This paper will explore the reasons behind the rise in pornography consumption and explore possible implications. One of the primary reasons for the increase in pornography consumption is the widespread availability of internet pornography [2,3]. Increased internet use allows pornography to be easily accessible to anyone with an internet connection [4]. The rise in porn consumption may also be attributed to societal attitudes toward sex. In recent years there has been a shift toward a more open and accepting attitude toward sexuality and sexual activity, which has made it more socially acceptable to view pornography. The destigmatization of sexual activities and sexuality has likely contributed to the increase in porn consumption [5].
The potential effects of the increase in pornography composition are varied and complex; we attempt to address the psychological aspect in this paper. Some studies we found in our research suggest that pornography can harm personality and relationships, leading to problems such as addictions, distorted views of sexuality, and decreased satisfaction in sexual relationships [1]. However, other studies have suggested that pornography can positively impact some individuals, such as providing a means of sexual education and increasing sexual pleasure [6]. Over 2.5 million people visit pornography sites every 60 seconds [7]. So what makes pornography consumption problematic? A Problematic Pornography Consumption Scale (PPCS) of 18 questions was made to distinguish between problematic and non-problematic pornography consumption. It is answered on a scale from one to seven; the higher the number, the more likely the individual will have problematic pornography use. The cut-off used for this scale is 76 [8]. Although not all articles in our paper used the PPCS, it is vital to address and define it here. It is also of note that PPCS is not used to diagnose addiction; in fact, there is no Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis for pornography addiction or problematic pornography consumption. In this meta-analysis, we will discuss the avenues of pornography consumption and its effects, which can help discern if pornography consumption should have a place amongst other addictive disorders.
We will first cover the general trend of the rise of pornography consumption since the early 2000s and how the accessibility of pornography has affected the millennial and younger generations in terms of physical sexual connections, family life, and individual well-being. This cultural change includes the explosion of social media and its usage during this time [4]. Social media has reduced the barriers to viewing pornography. For example, some social media sites, such as Twitter, do not regulate erotic materials, making pornographic posts available to anyone [9]. Following is the debate over the impact that COVID-19 has had on sexual and personal relationships in younger generations. This analysis will encompass how the pandemic has impacted pornography usage and how social isolation fits into the change in sexual and intimate relations. Finally, we will discuss problematic pornography consumption and its link to other addictive disorders and cluster B personality traits.
Learning outcomes addressed in this paper will include how to define and recognize problematic pornography consumption, how the increase in accessibility to erotic content can influence undesirable behaviors, what cluster B personality traits are and how they correlate with addictive personality behaviors, and the associations between problematic pornography usage along with other addictive disorders and cluster B personality traits.

Review
This meta-analysis was performed congruently with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) as shown in Figure 1 below. Our analysis follows a qualitative approach based on our results analysis of the articles used for this paper [10]. The inclusion criteria for all sections of this analysis include papers published after 1999, papers written in English, and papers inclusive of all genders. The exclusion criteria encompass studies performed outside the United States and studies performed specifically on a single group of individuals. To our knowledge, this is the first meta-analysis on this topic.

FIGURE 1: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
The PRIMSA flow diagram maps out the number of records identified, included and excluded, and the reasons for exclusions. This template is from http://prisma-statement.org/prismastatement/flowdiagram.aspx.
Throughout our study selection, 17,700 articles were found on the databases PubMed, Google Scholar, EBSCO, JAMA, and ScienceDirect. After removing duplicates, abstract screenings, and complete text screenings, we had 42 remaining articles to use in this paper. This exclusion was done by all authors independently. The same system was used to determine the papers for each section of this meta-analysis.

Part A: Rise in Pornography Viewing Since the Early 2000s and Effect on Masturbation vs. Partnered Sexual Acts
All papers in this section of our analysis include participants who engage in solo sexual acts versus engaging in partnered sexual acts. The number of participants was calculated for each paper. The majority of participant ages range from 18 to 50 years old. All studies also include both men and women of any sexual preference. We gathered data using the total number of participants in each study. We used that to calculate whether there was an association between a rise in pornography consumption and an increase in solo masturbation versus engaging in sexual acts with another partner. We searched for articles that described the changes in pornography views since 2000 and how this changed the frequency of solo masturbation compared to partnered sexual acts. To conduct this search, we first looked at pornography consumption since 2000, then adjusted our search to pornography consumption's increased effect on masturbation as shown in Table 1. Of the papers found, 42 met our inclusion and exclusion criteria yielding a total of Nt = 57,173 participants. Of the total papers in part A, participants were N1 = 46,282. Of these participants, N2 = 42,164 had an increase in pornography consumption, and it was additionally concluded that viewing pornography contributed to increased solo masturbation. However, some papers showed no change, decreased pornography consumption, or evidence of more engagement with a partner (reduced solo masturbation), N3 = 4,118. In this category of participants, viewing pornography did not affect partnered sexual relations. By dividing N2 by N1 and multiplying that by 100, we got a result of a 91.10% overall increase in pornography consumption from the year 2000. We also calculated the pooled proportion of the data for part A which included all the papers that fit the criteria for an increase in pornography consumption. The data shows a rise in pornography consumption for part A. A pooled proportion test was done to determine the percentage of increase, which yielded results showing us a value of 0.911. This further supports the 91.10% overall increase in pornography consumption. Additionally, we theorize that participants who consume pornography are more likely to perform solo sexual acts instead of partnered sexual acts. Figure 2 illustrates the difference in the number of papers that depict a rise in pornography consumption versus the papers without a rise.

Reference number
Year Number of participants Change in consumption Synopsis [11] 2015 1961 No effect Pornography views increased due to the expanded availability and affordability of materials.
[12] 2020 1031 rise Increased pornography consumption is linked to increased depression, anxiety, and stress. [13] 2008 813 rise Pornography use is positively associated with risky sexual behaviors, substance abuse patterns, and extramarital affairs. [14] 2004 1792 decrease Pornography consumption is associated to an increased risk of having partnered sexual relations. [

Since 2000
Showing, in tabular form, the data that was extracted from the 21 papers used for part A . Part A of our analysis is determining, via available previous research, if pornography consumption has increased in the United States and Canada since the year 2000.

Part B: COVID-19 and Its Effect on Pornography Consumption and Consequences on Sexual and Psychological Health
Next, we searched for articles on how the COVID-19 pandemic impacted pornography consumption. We then included the effect on sexual relationships; this includes how social isolation from the pandemic changed the dynamic of sexual encounters and how that impacted romantic and sexual relationships between people. After a review of all 42 papers was completed by all authors independently, 10 of those were used for part B of this paper. The total participants that demonstrated a rise in pornography viewing during the pandemic was N4 = 10,033. To get the total increase in pornography consumption during the pandemic we took the sum of N2 (42,164) and N4 (10,033) giving us a total sum of all pornography increases at N5 = 52,197. This analysis gave us the total number of participants for pornography consumption in parts A and B. To get the percentage of additional increase since COVID-19 compared to only the papers that had shown an increase in pornography consumption. We then took N4 divided by N5 multiplied by 100 to give us a 19% additional increase in pornography consumption since the COVID-19 pandemic. Data extracted from these papers are outlined in Table 2.

Reference number
Year Number of participants Synopsis [32] 2021 247 Decrease overall sex drive, increase solo sex and depression during COVID19 pandemic.
[33] 2022 1171 No significant difference in pornography consumption before and during the COVID19 pandemic.
[35] 2021 868 Covid 19 and social distancing caused initial increase in pornography views with problematic pornography use decreasing in men and remaining unchanged in women by August 2020.
[38] 2020 2608 COVID19 and social isolation caused decrease in partnered sexual activity, increase in pornography use, masturbation, and incidence of depression and anxiety.
[39] 2021 351 Increase depression and anxiety during COVID19 with no changes in partnered sexual activity.

Part C: Pornography Consumption and Its Relation to Other Addictive Disorders and Cluster B Personality Traits
Finally, we discuss if problematic pornography consumption is related to other addictive disorders and cluster B personality traits. Cluster B personality disorders include four groups: narcissistic, histrionic, antisocial, and borderline personality disorder. Cluster B personality disorders are characterized by overly dramatic and emotionally unpredictable thoughts and actions. The only DSM-5 addictive disorders are gambling, internet gaming disorder, alcohol use disorder, and substance use disorder. Although people can have compulsive behaviors of eating, shopping, and sex, just to name a few, these are not official diagnoses in the DSM-5. Addictive behaviors typically include compulsivity, impulsivity, neuroticism, and disinhibition to some degree. These addictive behaviors can accompany addictive disorders, cluster B personality disorders, and compulsive behaviors. We conducted separate searches for addictive disorders associated with pornography use and pornography use and its link to cluster B personality disorders. Of the 42 total articles, 10 of those were used for part C of this paper. Of the 57,173 total participants, only N6 = 16,771 participants fell into one of these categories. By taking the 16,771 participants that demonstrated addictive disorders or cluster B personality disorder traits and dividing that by the total number of participants, then multiplying that by 100, we could conclude that 36.6% of the studied population also exhibits addictive disorders or cluster B personality disorder traits. Shown below in Table 3 is how we took the data available to determine if there is any relationship between pornography consumption and other addictive behaviors [41][42][43][44]. This table also shows the relationship, or lack thereof, between pornography use and cluster B personality types [41,[45][46][47][48][49][50]. [41] 2018 273 Pornography use is associated with antisocial personality disorder traits, alcohol use, drug use, and increased violent behaviors. [42] 2018 13,778 Increased pornography use showed increased impulsivity and compulsivity.

number Year Number of Participants that fit into cluster B trait and/or addictive behaviors Synopsis
[45] 2022 1,250 Impulsive and antisocial traits are associated with erotic content use. [46] 2017 256 Narcissism was associated with extensive pornography consumption. [47] 2019 142 Pornography view rates correspond to compulsivity, narcissistic and histrionic personality traits. [48] 2014 257 Online pornography use positively corresponds to the level of narcissism.

TABLE 3: Pornography Consumption and Its Relation to Other Addictive Behaviors and Cluster B Personality Traits
Showing data extracted from part C looking at the relationship between pornography consumption, other addictive behaviors and cluster B traits.

Results
Part A discusses the rise in pornography consumption since 2000 and how that has caused an increase in solo sexual acts and decreased partnered sexual encounters. All papers in this section of our analysis include participants who engage in solo sexual acts versus partnered sexual acts. Our results conclude that there has been a 91.10% total rise in pornography consumption and solo masturbation since 2000. This result suggests that individuals are becoming increasingly dependent on pornography as a source of sexual gratification, decreasing the frequency of sexual encounters with partners. The data also shows that for all the papers that fit the criteria for an increase in pornography consumption, there was a pooled portion of 0.911. A value of 0.0889 resulted from the pooled proportion of data which showed no increase in pornography consumption. The standard error (SE) for this data set is 0.464. The z score was then calculated using the formula [Z=(p1 -p2)/SE] where p1 is the pooled proportion rise (0.911), p2 is the pooled proportion no rise (0.089), and SE is the standard error (0.004*100). With a z score of 1.76 this data is supportive. Using a one-tailed test we get a p-value of 0.039 which is significant compared to p < 0.05. These results are outlined in Table 4.

TABLE 4: The Total Rise in Pornography Consumption
Showing the results for part A, the total rise in pornography consumption since 2000. The first column shows the total number of participants in the articles used. The second column shows the number of participants, from the total number of participants, that had increased pornography consumption. The third column shows the number of participants, from the total number of participants, that had a decrease or no change in pornography consumption. The last column shows the total rise.
Part B uses the participants that demonstrated a rise in pornography consumption and solo masturbation from part A and compares them to the papers that depicted a rise in pornography consumption during the COVID-19 pandemic specifically. There was an additional 19% increase in pornography consumption due to the COVID-19 pandemic. These results are outlined in Table 5.  Showing the percentage of pornography consumption that increased further during the COVID-19 pandemic.

Rise in Pornography Consumption
Part C of our paper explored the associations between other addictive personality disorders and cluster B personality traits associated with pornography consumption. The total percentage of pornography viewers who also demonstrated other addictive disorders and/or cluster B personality traits yielded a pooled proportion for part C of 36.2%. Using the pooled proportion from part C we compared the results to the pooled proportion of part A to determine SE and z-score. SE between the two groups was 0.438 and the calculated z-score was 1.25. A two-tailed z-score of 1.25 corresponds to a p-value of 0.211 which is not significant compared to p < 0.05. This result is outlined in Table 6.

Personality Traits
Showing that there was not in fact any significant statistical evidence to support that pornography consumption is related to other addictive disorders and cluster B personality traits.

Conclusions
The limitations of this paper include publication bias, lack of long-term follow-up post-COVID-19 pandemic, lack of a universal scoring system for problematic pornography use, potential recall biases from studies used, and compounding. Our presumption of pornography consumption increasing since the year 2000 was supported by the data gathered which yielded a p-value that was statistically significant. However, our theory that problematic pornography consumption was associated with other addictive disorders and cluster B personality traits was not supported, due to only 36.2% of participants who demonstrated an increase in pornography use since 2000 also demonstrated an additional addictive disorder or cluster B personality trait characteristics. This finding is not significant since it gave a p-value of 0.211 which is greater than a significance level of p < 0.05. We found that there has been an increase in pornography consumption since 2000 and an even further increase during the COVID-19 pandemic. We found that during this increase there has been an increase in solo masturbation and fewer partnered sexual acts, with an increase in depression, stress, and anxiety levels. We believe this is associated with pornography consumption but is also due to isolation during the pandemic since pornography use increased even more during that time. This is indicated by the population proportion calculated, showing a 91% increase in viewers who fell into the increased category. The z-score for this data was 1.76 which corresponds to a onetailed p-value of 0.039 which is statistically significant compared to p < 0.05, indicating that the increase in consumption is supported by the data. The papers used in this meta-analysis are all from 2000 and more recent years to help associate pornography use with increased ease of accessibility. Since the 2000s the internet and social media have exploded. Because of this, erotic content has become more easily accessible and, at times, free of cost to consumers. The data collected from the papers for part B showed that the increase in pornography consumption during the pandemic was primarily driven by the increased time that individuals spent at home. With many people working from home and social distancing measures in place, individuals had more time on their hands. They turned to pornography as a source of entertainment and sexual gratification.
With pornography becoming increasingly accessible, we theorize that problematic pornography will continue to rise, resulting in either a standardized way to quantify pornography use or utilizing the PPCS as the quantifier for a pornography addiction diagnosis. We believe that further research can be done on this topic to help solidify the association, or lack thereof, between other addictive disorders and cluster B personality traits with problematic pornography consumption. Continued research on this topic could aid in determining if pornography use has a place alongside other addictive disorder diagnoses in DSM-5.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.